Standing Committee E

[Sir David Madel in the Chair]

Health and Social Care Bill

Clause 32 - Reviews of pilot schemes

Amendment proposed [this day]: No. 277, in page 30, line 37, leave out 'three' and insert 'two'.—[Mr. Hammond.] 
 Question again proposed, That the amendment be made.

David Madel: I remind the Committee that with this we are taking amendment No. 276, in page 31, line 4, at end add—
 `(5) The review referred to in this section must include a review of— 
 (a) the impact of the pilot scheme on patient services, and 
 (b) the cost effectiveness to the NHS of the pilot scheme, and 
 (c) the impact of the pilot scheme on retail competition. 
 (6) A report detailing the conclusions of every review under this section shall be published by the health authority concerned not less than three months after the completion of the review.'.

John Denham: Before lunch, I was about to set out our views on the review procedure that should be adopted. The clause leaves the procedure to be determined by the Secretary of State or the National Assembly, except that the health authority and the participants in the scheme should be able to make their views known. That is only a minimum requirement. We will need to develop our approach to the review in the light of experience. We shall want to learn continuously from experience, so that we can apply those lessons to later pilot schemes and, in due course, to the substantive arrangements for local pharmaceutical services when we are satisfied that the pilots have demonstrated that LPS works. We will build reviews of individual schemes into an overall programme of review and evaluation.
 Amendment No. 276 illustrates some of the difficulties of trying to put all the review criteria in the Bill. It is interested in retail competition in the widest sense, but not in the effects that the pilots have on people's health, which is an intriguing factor. Cost-effectiveness has been mentioned, but not reductions in inequalities between different sections of the community. I am not saying that the hon. Member for Runnymede and Weybridge (Mr. Hammond) is not interested in such wider issues, but it is difficult in practice to put in the Bill a comprehensive list of all the factors that should be taken into account in the review. We might want to look at others, such as the effect on the recruitment, retention and motivation of pharmacists or the relationships between different parts of the national health service. 
 One issue that we would want to consider is the extent to which the pilot had achieved its stated aim as set out in the original LPS contract. That will be a good starting point in many reviews. The personal medical services legislation on which we based the measure did not set out the evaluation criteria, for the good reason that it was considered then—as we consider now—that we need to build up our idea of what the review should contain in the light of experience. 
 As for whether reports should be published on all pilot schemes, there is no such requirement in connection with each and every PMS scheme and I am not persuaded that we need to treat pharmaceutical services differently. Of course, we shall want to learn lessons from pilots, make them widely available and disseminate them. In the case of personal medical services, we have commissioned a continuing evaluation of PMS pilots, which is published from time to time. It has informed our thinking on the third wave of PMS pilots. I am sure that there will be continuous feedback about LPS, but I do not believe that it would be a good idea to put into primary legislation a particular way of doing so or that a report should be published on every individual pilot. 
 Under amendment No. 276, the review would be undertaken within two years. I understand the hon. Gentleman's argument, but in reality it may take some time for a new pilot to build up to its full effectiveness. If we said that the review had to be completed within a couple of years, there may be only a year or a little longer on which to base it. The wording of the current clause, which is the same as that on personal medical services, is the probably the best route to take.

Philip Hammond: The Minister has outlined the case for not including the detailed requirements of the review in the Bill. I understand the logic of that, but there is not even a provision for the making of directions by the Secretary of State or the relevant authority on what the review should cover. It seems to be entirely at the discretion of the health authority.

John Denham: In this case, the relevant authority is the Secretary of State. I do not know whether it makes the hon. Gentleman feel better to know that the Secretary of State would ultimately determine the procedure.

Philip Hammond: It makes me feel better in the sense that the Secretary of State making regulations to guide the review clearly would not add anything. I would have preferred a provision in the Bill; the Minister will understand why we routinely plead for more detail in the Bill, but I accept that he has made a case for retaining the flexibility that exists in the PMS and PDS review mechanisms. I therefore beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn. 
 Clause 32 ordered to stand part of the Bill. 
 Clause 33 ordered to stand part of the Bill.

Clause 34 - NHS contracts and financial provisions

Question proposed, That the clause stand part of the Bill.

Philip Hammond: Perhaps we are rushing through the Bill just a little too fast, Sir David.

David Madel: The hon. Gentleman can always stop me.

Philip Hammond: Thank you, Sir David. That requires me to have my wits about me.
 In relation to clause 34, I should like to address the broader issue of NHS contracts versus conventional commercial contracts. Although we have now agreed that clause 33 stand part of the Bill—no amendments were tabled to it and no one objected to it—there is an issue to explore, which I touched on earlier, about the nature of the contracts that will be involved when a pilot scheme takes the form of an arrangement between a health authority and a private sector partner, typically a pharmacy chain or a supermarket chain. 
 In the normal course of events, the contracts would give the private partner the ability to make the necessary investment. The Minister acknowledged that there would be a problem if the termination provisions allowed for the contract to be terminated by a health authority on a whim or by direction of the relevant authority as no private sector partner would be able to raise the funding or be prepared to risk capital. 
 Clause 34(1) provides that a company or private body that wishes to enter into a pilot scheme may apply to be treated as a health service body. I understand the reason for the provision—they would then be party to an NHS contract, which, as with so many double speak exercises in the health service, is not a contract, but simply an arrangement that exists so as long as it reflects the will of the Secretary of State. It is not a contract in the legal sense or in the sense in which any commercial entity would understand the term; nor would any banker or financier lend for investment in such a project. 
 I cannot imagine that the Minister is seeking to undermine his own scheme first by providing in clause 33 that contracts may be terminated at the will of the Secretary of State and, secondly, by suggesting in clause 34 that people who would usually expect to enter into normal, legal, binding contracts should for these purposes become health service bodies and enter into arrangements that are not contractual or binding. Those provisions seem to undermine the principle that the Minister has outlined in mapping out the possibility of a partnership between health authorities and private sector entities particularly in relation to developing services in areas where they do not exist or where they are under-provided and require investment. Will the Minister address what will happen in those circumstances? 
 If a pharmacist who is currently providing part II services enters into a pilot scheme using existing premises, facilities and assets and the pilot scheme can be terminated in accordance with clause 33, and there is a return-ticket provision allowing them to go back to providing part II services under the 1977 Act, I accept that there is no particular problem and that in those circumstances it may make perfect sense to allow private pharmacists to become NHS bodies for the duration of the LPS pilot. However, that will not bring in the new resources and the new capital to which the Minister referred. Can he reassure the Committee that, where it is appropriate, there will be an opportunity within the pilot schemes for proper contractual arrangements that are bankable and will allow capital to be invested, that there will be a mechanism for effectively contracting them out of the provisions of clause 33 in order to make them bankable and that in those cases it would not be necessary for pharmacists to become health service bodies in order to enter into NHS contracts, which are rather less attractive from a banker's point of view?

George Young: My eye was attracted to the explanatory notes on clause 34 as paragraph 156 deals with the issue that my hon. Friend has just raised. It states:
 ``NHS contracts are not normally enforceable in the Courts.'' 
It is some time since I was a Health Minister, and I may have been aware of that, but had temporarily forgotten it. The NHS is a major employer. Is it really the case that those contracts of employment are not enforceable in the courts? Is it really the case that the major contracts that the NHS enters into with the private sector are not normally enforceable in the courts and the whole thing rests on the good will of the Secretary of State? 
 The next sentence says: 
 Instead, any disputes can be put to the Secretary of State ... for resolution.'' 
Will the Minister shed some light on that rather astonishing statement that the whole legal principle on which the NHS is founded rests ultimately on the mood of the Secretary of State as to whether or not he finds for the appellant. I assumed that it was subject to the rule of law and that was where disputes were resolved, but that sentence has somewhat undermined my faith in that concept. Perhaps the Minister can now put my mind at rest?

John Denham: I have been in the House long enough to be nostalgic for the days when explanatory notes were every bit as obscure as the clause that they sought to explain. There were never any such difficulties then. Clearly the attempt to express matters in more colloquial terms introduces a wider debate. I will try to reassure the right hon. Gentleman.
 The reference here is to what in the legislation are referred to as the contracts entered into between NHS bodies—for example, a commissioning arrangement between a primary care trust and an NHS trust—rather than the whole panoply of NHS contracts. I apologise if the explanatory note is not as clear and comprehensive as it might have been. 
 I can reassure the hon. Member for Runnymede and Weybridge that it is entirely a voluntary option for potential LPS providers to apply for health service body status. There is no question of anybody being required to go for health service body status in order to take part in LPS. If a provider did not wish to enjoy the health service body status, he or she would not need to do so in order to take part. Clearly, though, there will be circumstances—the hon. Gentleman identified one—where the ability to be treated as an NHS contract holder will be a more convenient way of arranging services and remuneration than a formal legal contract. There is a mechanism for the resolution of disputes and that, ultimately, is enforceable in the county court. It is a voluntary option and a significant number of LPS providers will probably wish to take advantage of it, but it is not a compulsory option. Therefore, the situation that the hon. Gentleman was concerned about—someone being forced to go down such a route, and the viability of the scheme being called into question—should not arise.

Philip Hammond: Does the Minister not recognise that there could be a problem in relation to termination?

John Denham: The common sense answer is that the parties to the agreement and the provider would have to consider what would happen in the event of a termination before applying for the health service status. As it is a voluntary option, it only arises if somebody chooses to go down that particular route.

Philip Hammond: I think that the Minister slightly misunderstood what I said. Someone who chooses not to go down that route will still not have the assurance of an enforceable contract, because of the possibility of the contract being terminated by a direction of the relevant authority. The only practical route for a private sector party would be to build in to the contract cancellation provisions that recompensed that body for its investment. The health authority would then be exposed, because it must follow a direction given by the Secretary of State to terminate a scheme. However, it is not conceivable that a private sector investor would invest substantial sums unless the contract were phrased in such a way that the investor would be compensated in such an event.

John Denham: That is an issue in relation to clause 33, which we discussed briefly, rather than clause 34. The reality is that we cannot disapply clause 34. The Secretary of State must have the power to terminate a pilot in circumstances, which I am sure will be rare, in which a scheme proves to be totally unsatisfactory. The various parties will need to consider the consequences of that before deciding to enter into the scheme.
 Question put and agreed to. 
 Clause 34 ordered to stand part of the Bill. 
 Clause 35 ordered to stand part of the Bill.

Clause 36 - Charges, recovery of payments and penalties

John Denham: I beg to move amendment No. 209, in page 32, line 29, leave out 'piloted' and insert 'local pharmaceutical'.

David Madel: With this it will be convenient to take Government amendments Nos. 210, 211 and 223.

John Denham: The clause has a simple policy intention—that there should be no difference whatever between existing services and LPS pilot schemes in terms of prescription charges. The consequences should be the same for a patient who pays the prescription charge, or who makes a declaration to say that they do not need to do so, in all pharmacies, whether or not they are LPS pilots. Equally, the consequences should be the same for not paying a charge, which is why the clause provides the power to make regulations to apply penalty charges when exemption from payment is wrongly claimed. In serious cases, prosecution will be possible under section 122C of the Health Act 1997.
 Government amendments Nos. 209 to 211 ensure that the status quo on prescription charges is maintained. The amendments alter subsections (1), (2) and (3) to make sure that the powers apply only to pharmaceutical services. The original drafting would have given schemes the power to charge for all services provided under pilot schemes, which was not our intention. By adding a further paragraph to schedule 3, Government amendment No. 223 provides the same regulation-making powers for substantive LPS schemes once they are introduced. 
 Amendment agreed to. 
 Amendments made: No. 210, in page 32, line 35, leave out `piloted' and insert `local pharmaceutical'. 
 No. 211, in page 23, line 38, leave out `piloted' and insert `local pharmaceutical'.—[Mr. Denham.] 
 Clause 36, as amended, ordered to stand part of the Bill. 
 Clause 37 ordered to stand part of the Bill.

Clause 38 - Control of entry regulations

Question proposed, That the clause stand part of the Bill.

Desmond Swayne: In many respects, my constituency is patchy with respect to the coverage that can be had from pharmacists—we are certainly talking about many more than the three miles that were mentioned this morning by the hon. Member for Isle of Wight (Dr. Brand). That position would be much worse if one or two strategically placed independent pharmacists were to find themselves in greater difficulty because of current trading conditions.
 My constituency is served by independent pharmacists. Although the total number of chemist shops in the United Kingdom has remained stable at approximately 10,000, the composition of those shops has changed significantly. Over the past 10 years, the proportion of chemist shops that are part of a chain of more than five shops has risen from approximately 25 per cent. to 40 per cent. There has been quite a concentration in the market with the growth of chains at the expense of independents. 
 The smaller independents inevitably face various disadvantages, such as the fact that a flat fee is paid as part of the system, whereas in the past, fees took account of the low volumes used by smaller independent outlets. The national health service expects pharmacies to negotiate discounts with wholesalers, and reimbursement is based on that. It does not take account of the differential ability of small independents to negotiate significant discounts with wholesalers. There is the additional question of the high-cost item for which the fee fails to reimburse the small independent for the cost of his borrowing while he waits 90 days to be reimbursed for the cost of the item. 
 It is for those reasons that many independent chemist shops have disappeared. I believe that the change in the structure of the market because of the disappearance of the independent can profoundly alter the relationship with the pharmacist. It is precisely because of the informal circumstances in which people meet their independent local pharmacist that they are able to obtain more information from the pharmacist than from their doctor. I would argue that local pharmacists provide a different quality and level of service. 
 The provisions in the Bill offer greater opportunities for independents. There is every prospect that the LPS arrangements will play to the strengths of the independents in the quality of the service that they offer. It would be tragic if at the same time, the control of entry criteria were changed to the extent that competition knocked many of those independent suppliers over the edge and drove them out of business. I am essentially seeking reassurance from the Minister. Will he describe the circumstances in which the control of entry criteria will be changed or removed in their entirety so as not to bring about a faster change in the structure of the market, with the disappearance of independents, than has already been the case, most regrettably, over the past 10 years?

John Denham: I think that I can give the hon. Gentleman the reassurance that he seeks. We have already discussed the relationship between proposed LPS pilots and existing contractors. Clause 38 seeks to deal with the relationship between LPS pilot schemes that are already in operation and new applications under the national arrangements. If a pharmacy moves from national arrangements to an LPS pilot scheme it will typically still remain in competition with other pharmacies, and it would be odd if such pharmacies were afforded less protection than they had before.
 Clause 38 is designed for the circumstances that the hon. Gentleman described. If a pharmacy takes advantage of LPS and believes that it has particular strengths to move in that direction, it should not lose the protection that it would have had under the national arrangements. Clause 38 will ensure that pilot scheme pharmacies are taken into account when health authorities decide whether existing services in the neighbourhood are adequate.

George Young: Can the Minister give a similar assurance in respect of the circumstances that we discussed this morning where pilot schemes are provided not under LPS but under PMS? Will they be similarly safeguarded?

John Denham: We discussed the role of PMS in providing innovative services. There is conceptually a difference between a PMS pilot or any other service that is restricted to dispensing to the patients of a particular practice and a LPS scheme or general national contract pharmaceutical service scheme that provides dispensing services to all the patients in the area who hold an NHS prescription. We are doing nothing to change the existing provisions, but the right hon. Gentleman's example is not analogous to the provision for local pharmaceutical service schemes, which is particularly to ensure that a pharmacy that enters into a pilot scheme is afforded the same protection that it would have had under the national contract.

George Young: I am not sure that I have fully understood the Minister. Is he saying that what can be provided under PMS is more restrictive than what is provided under LPS? The final sentence of paragraph 4.12.3 of ``The Health and Social Care Bill: Local Pharmaceutical Services'' implies that the same services can be provided under either PMS or LPS.

John Denham: I confess that I am not quite sure to what the hon. Gentleman is referring.

George Young: It is the document that has helpfully been provided called ``The Health and Social Care Bill: Local Pharmaceutical Services''. I will read out paragraph 4.12.3 in order to give the Minister's officials time to concoct a response. It says:
 ``The opportunity for innovation within a local contract therefore already exists, and it is likely simply to become confusing if the same services could be provided under either PMS or LPS.'' 
I took that to mean that it did not matter that a general practitioner was precluded from applying for a pilot scheme under LPS because he could apply under PMS and do exactly the same. However, in his response a few moments ago about the protection provided under clause 38, the Minster was unable to give me the assurance that I was seeking, that somebody who provided exactly the same services under PMS would receive protection under clause 38. I wanted an assurance that whichever door one knocked at to provide the services, one would receive clause 38 protection.

John Denham: I set out in earlier discussions the distinction that we draw between dispensing doctor arrangements and pharmaceutical services and the reason why we do not apply the same entry criteria and competition criteria to the two. On the question of how that affects the PMS service, I accept that there is a contradiction between what I have just said and the document that I circulated previously. It may be helpful if I write to the right hon. Gentleman to clarify that point.
 Question put and agreed to. 
 Clause 38 ordered to stand part of the Bill.

Clause 39 - Assessing pilot schemes

John Denham: I beg to move amendment No. 212, in page 33, line 21, at end insert—
`(within the meaning of section 128(1) of the 1977 Act)'.
 The amendment is purely technical. It simply corrects an oversight by adding a definition of the term ``health service'' used in subsection (1). 
 Amendment agreed to. 
 Clause 39, as amended, ordered to stand part of the Bill. 
 Clause 40 ordered to stand part of the Bill.

Schedule 3 - LPS schemes

1Amendments made: No. 220, in page 62, line 11, leave out— 
`has such meaning as may be prescribed' 
and insert— 
`means such services of a kind which may be provided under section 41 of this Act, or by virtue of section 41A of this Act (other than practitioner dispensing services) as may be prescribed; and 
 ``practitioner dispensing services'' means the provision of drugs, medicines or listed appliances (within the meaning of section 41) by a medical practitioner or dental practitioner to a patient of his pursuant to arrangements made by virtue of section 43(1).'. 
No. 221, in page 63, line 1, leave out from beginning to end of line 2.—[Mr. Denham.]

John Denham: I beg to move amendment No. 222, in page 63, line 19, leave out `of a prescribed description' and insert—
`determined in accordance with the regulations'.

David Madel: With this it will be convenient to take the following:
 Government amendment No. 284. 
 Government new clause 12—Premises from which piloted services may be provided.

John Denham: We are moving at such a rate that I am losing track.
 Amendment No. 284 and new clause 12 deal with the movement of people from national arrangements to LPS and vice versa. New clause 12 deals with pilot schemes, while amendment No. 284 deals with the substantive, post-pilot arrangements, by adding further sub-paragraphs to paragraph 3 of schedule 3. 
 In both cases, the amendments provide powers to prevent people from providing services under both LPS and the national arrangements from the same premises. That is only sensible. In most cases it would be virtually impossible to tell when a prescription was being dispensed under LPS and when under the national contract. To let the two run side by side would be a recipe for confusion and—conceivably—fraud. 
 However, as with the equivalent provision for PMS, we do not think there should necessarily be a blanket ban. It is possible to imagine circumstances in which it might make sense for LPS to be provided from premises where services under national arrangements are also provided. For example, an LPS scheme might focus on out-of-hours services. In that case, there could be a clear distinction between LPS and the national arrangements, even though the same premises were used. Regulations will be able to make exceptions to the general rule. 
 The amendments provide a basis for regulations about transfer to and from pharmaceutical lists—the lists held by health authorities of the people with whom they have arrangements to provide services under the national contractual framework. When pharmacies move into LPS schemes, they will generally stop providing services under national arrangements, and so will need to be removed from pharmaceutical lists. The amendments provide for that. 
 Rather more significant for pharmacy owners will be the question whether they will be able to return to the national arrangements if, for any reason, their LPS scheme does not work out. The arrangements will be similar to those for PMS. Before people start providing LPS, they will be told whether they will have a preferential right to return—or in the case of new providers, transfer—to the national arrangements. Such a right will mean that they do not have to go through the normal control of entry procedures when they apply to go back on to the pharmaceutical list. Decisions about rights of transfer and return will be taken by the Secretary of State for pilot schemes and by health authorities for the later substantive arrangements. 
 Amendment No. 221 removes a small inconsistency in the drafting of the regulation making powers in paragraph 3(3)(a) of schedule 3. 
 Amendment agreed to. 
 Amendments made: No. 284, in page 63, line 28, at end insert— 
`( ) prevent (except in such circumstances and to such extent as may be prescribed) the provision of both LP services and pharmaceutical services from the same premises; 
 ( ) make provision with respect to the inclusion, removal, re-inclusion or modification of an entry in respect of premises in a list under section 42;'.
 No. 223, in page 63, line 42, at end insert— 
 `.—(1) Regulations may provide for the making and recovery, in such manner as may be prescribed, of charges for local pharmaceutical services. 
 (2) The regulations may, in particular provide for— 
 (a) exemptions from charges; 
 (b) the liability to pay charges to be disregarded in prescribed circumstances or for prescribed purposes; 
 (c) section 122A of this Act (recovery of certain charges and payments) to apply also in relation to local pharmaceutical services (with or without modification); 
 (d) section 122B of this Act (penalties) to apply also in relation to local pharmaceutical services (with or without modification). 
 (3) The regulations must secure that the amount charged for any service is the same as the amount that would be charged for that service if it were provided under Part II of this Act.'.—[Mr. Denham.]
 Schedule 3, as amended, agreed to

Clause 41 - Application of enactments

John Denham: I beg to move amendment No. 281, in page 33, line 39, leave out from beginning to end of line 2 on page 34 and insert—
 `( ) The relevant authority may by regulations make, in relation to Schedule 8A arrangements or persons providing or assisting in the provision of services under such arrangements, provision corresponding (whether or not exactly) to enactments containing provision relating to—
(a) arrangements made under section 28C of the 1977 Act (provision of personal medical or dental services); or
(b) pilot schemes made under Part I of the National Health Service (Primary Care) Act 1997,
or relating to persons who provide or perform services under them.'.

David Madel: With this it will be convenient to take Government amendments Nos. 282 and 283.

John Denham: The clause is intended to provide the power to make regulations so as to apply to local pharmaceutical services other aspects of the existing legislation about PMS and PDS that are not explicitly covered in the Bill. As there is already a well-established model to follow in the NHS (Primary Care) Act 1997 and elsewhere, it does not seem necessary to go into the same exhaustive detail in the Bill. The main elements of LPS arrangements are covered in the clauses with which we have already dealt. This regulation-making power will allow us to deal with the remaining details by applying the existing model, with modifications where necessary. For example, it will allow us to extend the role of local pharmaceutical committees to representing those LPS providers who want such representation.
 On reflection, we concluded that the powers originally drafted did not meet our requirements. Government amendment No. 281 replaces subsection (1) with a more extensively drafted and clearer provision. Government amendments Nos. 282 and 283 make consequential changes to subsection (2). The resulting power will remain limited to mirroring legislation that applies to PMS and PDS, but it will be expressed rather differently. The amendments make it clear that the Bill covers provisions not only about PMS and PDS arrangements, but also about the people providing and performing them. 
 Amendment agreed to. 
 Amendments made: No. 282, in page 34, line 4, leave out `provision' and insert `such enactment'. 
 No. 283, in page 34, line 4, after `modifications', insert `, if any,'.—[Mr. Denham.] 
 Clause 41, as amended, ordered to stand part of the Bill.

Clause 60 - Extension of prescribing rights

John Denham: I beg to move amendment No. 217, in page 54, line 7, at end insert `;
(h) any other description of persons which appears to the appropriate Ministers to be a description of persons whose profession is regulated by or under a provision of, or made under, an Act of the Scottish Parliament or Northern Ireland legislation and which the appropriate Ministers consider it appropriate to specify.'.

David Madel: With this it will be convenient to take Government amendments Nos. 213 and 216.

John Denham: It may be helpful if I explain briefly how the next few clauses relate to one another. Clause 60, together with clause 44 and parts of clause 42, deals with the extension of prescribing rights. The remainder of clause 42 and clause 43 deal with the remote provision of NHS pharmaceutical services--home delivery, mail order and internet services. The genesis of these clauses is the final report of the ``Review of Prescribing, Supply and Administration of Medicines'', which was published in March 1999.
 The review, by Dr. June Crown, made a number of recommendations relating to the prescribing and supply of medicines. One of its major recommendations was that legal authority to prescribe in the United Kingdom, including authorising NHS expenditure, should be extended beyond the current prescribers--doctors, dentists and some nurses. It also recommended that legal authority for new professional groups to prescribe should normally be limited to areas within the expertise and competence of each group. Two types of prescriber were recognised: independent prescribers, who would be responsible for the assessment of patients with undiagnosed conditions and for decisions about their clinical management, and supplementary prescribers, previously known as dependent prescribers, who would be responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. The review also recommended that Ministers should receive advice on granting prescribing rights to new professional groups from a UK-wide advisory body, set up under the Medicines Act 1968. 
 The provisions in clauses 60, 44 and parts of clause 42 help us to implement the review's most important recommendations. Clause 60 amends section 58 of the Medicines Act 1968, and deals with the prescribing of prescription only medicines, whether privately or dispensed as a cost to the NHS. Clauses 42 and 44 make like changes to the National Health Service Act 1977, in respect of ordering drugs and other items on the NHS. 
 We consulted the NHS and relevant professional organisations before agreeing to implement the main recommendations of the review. A strong majority of the organisations consulted on the review's recommendations were in favour of extending prescribing rights to other health professionals. That is why we are now taking powers that will enable us to implement those recommendations through orders. I 
 was glad that on Second Reading the proposals were supported by both sides of the Chamber. Action to extend the rights to prescribe medicines will help to break down the divisions between health professions and play an important role in the introduction of more flexible team working throughout the NHS. 
 I shall give one or two examples of the potential benefits of extended prescribing rights. Physiotherapists may be able to prescribe non-steroidal anti-inflammatory drugs and analgesics rather than having to refer their patients to a GP, and optometrists could prescribe medicines for the treatment of conjunctivitis and other eye infections. However, the proposals will also mean better and speedier access for patients to the medicines they need, as envisaged in the NHS plan. 
 Clause 60 does not confer any prescribing rights. Instead, it makes it possible for Ministers to extend by order such rights to members of any recognised and regulated health profession. Patient safety will, of course, be paramount during implementation, particularly when considering whether to grant prescribing rights for specific medicines to a professional group. An advisory body under the Medicines Act will take account of concerns when considering the granting of prescribing rights to any specific group of health professionals. That advisory body will make recommendations to Ministers. More detailed proposals for granting prescribing rights for specific medicines to a particular group of health professionals will be subject to both informal and formal consultation with relevant organisations. 
 The Government amendments are related. Clause 60(3) lists the registered health professionals who may be considered for prescribing rights. Government amendment No. 217 extends that list to ensure that health professions, regulated under separate Scottish and Northern Ireland legislation, have the same potential right to prescribe as health professionals regulated under the specified Acts of Parliament. 
 Clause 42(3) lists the registered health professionals whose prescriptions may be dispensed under the NHS in England and Wales. Government amendment No. 213 extends that list to ensure that prescriptions of Scottish and Northern Irish regulated professionals will be able to be dispensed in England and Wales. 
 Finally, clause 44(3) lists the registered health professionals whose prescriptions may be dispensed under the NHS in Scotland. Government amendment No. 216 amends that list to make similar provisions in Scotland for health professionals regulated under Northern Ireland legislation.

Desmond Swayne: I have a number of questions for the Minister. First, how will the advisory body be constituted? Will it comprise members of the professions that are to obtain prescribing rights under the regulations? The Royal College of Nursing wants to know why midwives and nurses are not included in the list in amendment No. 213. He will be aware that the limited content of the current nurse prescribers formulary has proved frustrating, and that the royal college wants the full British national formulary to be accessible to all licensed nurse prescribers.
 The electronic mail message that I received from the royal college states: 
``The RCN calls on the Government to ensure that nurses who have specialist training can prescribe controlled drugs as well as having access to an increased range of other prescription only medicines. This would mean, for example, specialist pain control nurses could prescribe controlled drugs such as diamorphine for patients with a clinical need.'' 
That description seems consistent with what the Minister said about different groups with different expertise being able to prescribe in a particular way. Will he respond to that point when he answers the debate? 
 Concern has been expressed about the degree of restriction that regulations may place on legitimate prescribing powers. If regulations are to specify in detail what drugs can be prescribed and in what circumstances, they will rapidly become cumbersome and out of date. It will be difficult for dispensing pharmacists to keep abreast of changes in products and what is available for patients. The benefits that those patients may obtain from those products, and the most up-to-date clinical practices will be constrained by regulation . How quickly can we expect the regulations to be reviewed to accommodate pharmaceutical developments? 
 There must be absolute clarity about where clinical responsibility lies. Perhaps the Minister will say something about that. Will it lie with those who gain the new prescribing rights? The Minister commented on the independence of those people, but the implications were not clear. Will the new prescribing rights be independent of the existing prescribers—general practitioners and consultants—or will they be dependent on an existing prescriber, who will take full responsibility? 
 What safeguards does the Minister plan to provide to ensure communication between multiple prescribers, to avoid interactions between the drugs prescribed for a patient by several eligible professionals?

Peter Brand: The Minister is right to attempt to outline the professional groups that should have prescribing rights and to consider specific drugs in relation to those groups. I also invite him to consider the specific settings or circumstances under which prescribing takes place. I share some of the concerns expressed by the hon. Member for the nicer bit of the New Forest—the hon. Member for New Forest, West (Mr. Swayne)—as accountability and teamwork should be strengthened rather than confused by the provisions.
 Let us deal with dependent prescribers—that is not a happy term—in a hospital. I imagine that a specialist diabetic nurse would prescribe according to protocols accepted by the diabetic team, which would include a consultant. If so, there should be shared accountability within that team for what happens to the patient. If prescribing occurs outside that unit, the nurse practitioner would become responsible by himself or herself. 
 It would be nice if the Minister gave some thought to the possible conflicts within a team. A specialist asthma nurse may be keen to follow the guidelines of the British Thoracic Society--which are excellent, although some eccentric asthma physicians do not hold by them. The nurse prescriber would have a good basis to act independently as a prescriber, but would be in a difficult position if the consultant, who was part of an asthma team in a hospital, was not prepared to back up the prescriptions that had been issued. 
 In primary care, teamwork has probably evolved more than in hierarchical, hospital-based structures. However, there is sometimes wooliness as to who is a member of the core primary care team and who is an adjunct, and therefore important but not integral. Where does the definition of dependent and independent prescriber begin and end? 
 Clearly, independent practitioners—physiotherapists, ophthalmologists and others who rightly have wider prescribing rights—would not necessarily fit into a primary care team on a day-to-day basis. It is more difficult for them to share local protocols on how to deal with particular diseases. In the relevant circumstances, the practitioner would be totally responsible for the prescribing, in the same way as a practitioner, a nurse practitioner or a pharmacist in a walk-in centre should be responsible for a prescription that he or she has issued. I am, however, slightly concerned about the lack of a clear mechanism by which the responsibility could be passed on to members of the team caring for the patient. 
 General practitioners are worried about the case law covering what could happen once a hospital pathology department or diagnostic imaging department had obtained abnormal results, in a process that had been initiated by a hospital consultant, and had sent a copy to a general practitioner. If the hospital failed to act on the abnormal results, and things went amiss, and if the GP had not acted on the results that were copied to him or her, there would be joint liability. I am slightly concerned, given the proliferation of agencies that are now involved with the care of patients, that that could become an increasing problem. 
 Out-of-hours co-operatives have established a fairly tight regime of information sharing and handing over of responsibilities. When an out-of-hours service ceases to operate at 8 o'clock in the morning and passes over the notes of the events of the night, liability for the patients transfers immediately back to the GP with whom the patient is registered. In a walk-in clinic matters are not so clear. The GP may not receive notification. There is no statutory responsibility to share information. 
 Information may be shared in the form of a fax that arrives at 11 o'clock on a Saturday morning, which may not be seen until 11 o'clock on a Monday, after the Monday morning rush, when people begin to look at the faxes that have arrived. In the meantime, for a day and a half the patient concerned may have been on inappropriate treatment, or may have needed further treatment, without follow-up. Would that situation impose a liability on the practitioner, who had not sought the information but on whom it had been thrust? Would responsibility be thrust upon the practitioner? 
 My difficulty with clause 60 is that all such matters are left to regulations. Issues of accountability are very important, and I wonder whether the Government are being unwise in not specifying in the Bill where responsibility will lie for the actions of the professional groups that they are rightly including in the provisions. The need for insurance and legal accountability can of course be discussed under amendment No. 278, which will no doubt be moved by the hon. Member for New Forest, West, but I should like the Minister's response on the general points.

John Denham: Hon. Members have raised wide-ranging issues, which I shall deal with as succinctly as possible.
 The hon. Member for New Forest, West first asked about the nature of the advisory committee. The power is given under the Medicines Act 1968 either to create a new committee or to ask an existing committee, such as the Committee on Safety of Medicines, to make recommendations to Ministers on which medicines may be prescribed by new groups of prescribers. The Bill allows a committee to be established or an existing committee to be given that responsibility before clause 60 comes into force. We shall not decide until later this year whether to build on the experience of existing committees, such as the Committee on Safety of Medicines, or to establish a new committee. However, the existing body has a great deal of relevant expertise, and I hope that the hon. Gentleman will accept my assurance that a newly established body would be based on the experience of relevant health professionals. 
 The second issue raised by the hon. Gentleman was about prescribing by nurses. The Crown report, which will be implemented under the Bill, drew a distinction between independent prescribers and supplementary prescribers. Under the Medicinal Products: Prescription by Nurses etc Act 1992, nurses are already able, under certain circumstances, to act as independent prescribers, which means that they take on the full clinical responsibility for their prescriptions. The Bill also allows nurses and other professions to act as supplementary prescribers. One reason why nurses are not included as independent prescribers is that they already have that power. 
 Between October 2000 and the beginning of 2001, the Department consulted on proposals to extend nurse prescribing over a wider range of medicines and a wider group of nurses. We received hundreds of comments and are examining them carefully. That consultation, in part, explored the issue raised by the hon. Gentleman. We could work through the entire formulary, saying that some drugs could be prescribed and others not, but about 17,000 different items are listed. We would either have to start again whenever new drugs came into the formulary or issue a more limited list. We may identify other ways of setting out the categories of drugs appropriate for nurse prescribing. The consultation document raised that issue: from memory, it set out five options, but we have not formed a firm view about which one to pursue.

Desmond Swayne: Can I edge the Minister towards a view? The royal college put its view forcibly that the whole formulary should be available to nurses, and that it should be up to them to use their professional discretion not to prescribe outside their areas of expertise. Nursing is, of course, a professional organisation and is regulated as a profession. We should expect nurses to take that responsibility.

John Denham: I understand that that is the view of the Royal College of Nursing; it will have been reflected in responses to our consultation. However, counter views have been expressed that must also be taken into account; some have argued that only those who have gone through a full medical training should automatically be assumed to have the ability to prescribe freely from the entire national formulary. We consulted on that issue, and Ministers will have to consider it and bring forward recommendations in due course.On the hon. Gentleman's original question, nurses have independent prescriber rights and will be able to have supplementary prescriber rights under the Bill.
 The hon. Gentleman raised an important point, which we shall need to address through guidance, about communications between people who may be prescribing under different circumstances. We shall obviously have to get that right. The investment that we are making in the development of the electronic patient record should ease that considerably. It should also deal with some of the issues raised by the hon. Member for the Isle of Wight about the transmission of information from NHS Direct, out-of-hours services or walk-in centres to a GP. We will need to ensure that there is an appropriate flow of information between one prescriber and another. 
 That is likely to be particularly important for independent prescribers who are exercising full clinical responsibility for the decisions they take about the prescriptions that they write. It is obviously an issue for supplementary prescribers, too, but they will be prescribing under the oversight of independent prescribers. For the supplementary prescriber, it is the independent prescriber who retains overall clinical responsibility. 
 The hon. Member for the Isle of Wight raised a wide range of issues, some of which go to beyond the provisions of clause 60. Currently, two independent prescribers, such as a GP and a hospital doctor, may take decisions about the same patient.

Peter Brand: The Minister is right, but accountability in that case is absolutely clearcut. Responsibility for the overall care of a patient in a hospital is taken by the consultant through clinical governance, and eventually by the chief executive of that hospital. As soon as the patient comes out of hospital, unless on leave as a patient under the mental health legislation, the responsibility becomes totally that of the general practitioner. There may occasionally be a dispute when patients have their pills changed between hospital visits and coming out, and vice versa. That system may not be desirable, but the accountability is clear, whereas in the Bill it is not.

John Denham: The principle must surely be the same as it is now, so by extension accountability must lie with the prescriber and the organisation to which they are responsible. The hon. Gentleman has highlighted the need to work closely with the professions when we implement the clause so as to deal with the practical issues arising from the extension of prescribing powers and to ensure safety and clear accountability. The hon. Gentleman said that we should have provided for that in the Bill. I suspect that it is better to try to achieve that outcome through the regulations, rather than attempt to anticipate or predict every possible eventuality in the Bill. I know that the hon. Gentleman supports the broad thrust of Government policy, and I am sure that he will be the first to scrutinise the more detailed proposals as they are introduced. He obviously has great knowledge and expertise in this area.

Peter Brand: In that process, will the Minister also consider the requirements for clinical governance and re-accreditation of prescribers in exactly the same way as doctors are, quite rightly, required statutorily to undergo re-accreditation and to audit their work through clinical governance?

John Denham: Re-validation of doctors, re-certification of dentists and the equivalent process in other professions are the responsibility of the professional bodies. Just as for consultants' contract we have tried to ensure that NHS appraisal of consultants directly ties in with, aligns with and is supportive of the General Medical Council's re-validation process, we will want to ensure that we are supportive of reasonable measures by other professional organisations to make sure that their members are fulfilling their proper professional responsibilities. We work with the professional regulatory organisations in the area of professional regulation. Clearly, the narrower area of prescribing in the NHS, to which this provision largely applies, must come within the NHS's own clinical governance arrangements. We should bear in mind the fact that not all the prescribing rights under discussion would be exercised within the NHS as full professional responsibilities. We must co-operate with the professional organisations for all the professionals in that category, and ensure that we have the right clinical governance arrangements in the NHS, where most of those people will be working.

Desmond Swayne: Could I bring the Minister back to the problem of the regulations becoming over-prescriptive, so that it would be difficult to revise them to keep abreast of pharmaceutical developments? How will the regulations work? Will they be general, enabling regulations, or will they specify, in detail, who may prescribe what? If the latter is the case, the effect may be to deny patients some of the most up-to-date developments simply because of the limitation of the regulations.

John Denham: All that I can say is that I do not have the answer to that today, but we will have to get it right for the extension of nurse prescribing. It is reasonable to assume that nurses will have a wider range of prescribing responsibilities than the other health professionals who will be covered by the legislation. The options that we put forward in our consultation document range from the ability to prescribe absolutely anything to the ability to prescribe from a list of five permitted items. There are various options in between those two extremes, ranging from building up an approved list to ruling out certain types of prescribing. We have not yet completed our response to that consultation.
 Eventually, we may need to take different approaches to different professional groups. Some of those mentioned in the legislation may have a very limited formulary available to them, certainly in the early days. Having a list of approved items may be the way forward—I do not know. For others, we may need a more flexible approach. I acknowledge the relevance of the hon. Gentleman's point, but we should examine the matter in detail in the context of the current consultation on nurse prescribing rights. We must ensure that we get it right.

Peter Brand: The Minister is right in saying that most of the work will be done by members of NHS-based teams. I support the plea of the hon. Member for New Forest, West that we should not restrict members of those teams by sheer formulae, because that has been so frustrating in nurse prescribing. Everyone should be able to work within their competence to the benefit of patients. There is often a shared approach, and perhaps the question of who should prescribe what should be determined locally.
 I would be worried if the Minister were suggesting that membership of a professional group would determine what a person could prescribe. The Minister has a real problem. Presumably, once an item is allowed for those belonging to a professional group, from that point on it would be allowable on the basis of only two criteria: the specificity of drugs and membership of that professional group. Such an arrangement would give scope to independent practitioners, some of whom are wonderful and invaluable, and join in with the teamwork, but a number of whom have exiled themselves from teamwork in the NHS, because they have eccentric ideas. It is important to recognise the different pressures on people who are not part of a therapeutic team. Audit and control of those groups is important. This part of the Bill greatly extends not only responsibilities, but opportunities for doing harm. 
 As the Minister acknowledged, I support the widening of prescribing powers. The present powers are demeaning to professionals. That is nothing to do with teams having to be doctor-led or anything like that; it is about protecting the patient, which is best done through teamwork and shared responsibility. However, the Minister must recognise that we are opening the door to people working in isolation, and to people not being prepared to link into the NHS network—or into private networks that work for the benefit of patients rather than practitioners.

John Denham: I did not intent to give the impression that clause 60 provides that this group must have the same power under all circumstances. For example, it is necessary for prescribing nurses to be specifically trained in prescription before they can prescribe. Clearly, location and function is important, not just the membership of a profession or a wider policy. The hon. Gentleman is right about that.
 Amendment agreed to.

Desmond Swayne: I beg to move amendment No. 278, in page 54, line 12, at end insert—
`(1C) An order under subsection (1A) may specify requirement as to indemnity insurance which must be maintained by a person exercising any rights conferred upon him by such order.'.
 The amendment would provide a useful power for the Secretary of State when making orders under subsection (1A). It would enable him, but it does not require him, to specify that indemnity insurance should be maintained by those exercising rights conferred on them by such orders. In other words, those who have acquired the new prescribing rights may, at the discretion of the Secretary of State, have to take out indemnity insurance. 
 It is a probing amendment, to try to put pressure on the Minister to explore what should happen when something goes wrong and where liability should lie. It would also have the useful function of providing a means of redress through indemnity insurance. However, I caution the Minister, because indemnity insurance is not a cheap option—I am sure that he already knows that. Such insurance is, by custom, relatively expensive, and Ministers may wish to protect professionals from that requirement and allow the NHS to continue to pay out rather than have the professionals paying out through insurance. That is an entirely proper consideration.

Peter Brand: It is a useful amendment. Indeed, I hope that the Government will consider tabling a similar amendment on Report. Some members of the national health service family are already covered through national health service indemnity arrangements, but it is vital that those who are not otherwise covered—especially those working independently—should carry indemnity insurance or be a member of an association that covers them, otherwise patients will be left without effective redress should things go wrong.
 3.45 pm

John Denham: The amendment raises a series of interesting issues. As the hon. Member for New Forest, West said, it would give Ministers the power by order to require new prescribers to carry indemnity insurance. It is possible to see both sides of the argument. In some cases, legislative powers already exist—for instance, the Health Act 1999 provides the power to regulate new professions. On the other hand, the vast majority of registered health professionals already carry indemnity cover through their membership of professional organisations or trade unions. For example, physiotherapists and chiropodists carry indemnity insurance through their membership of their professional bodies, the Chartered Society of Physiotherapists and the Society of Chiropodists and Podiatrists. The UKCC, which is the statutory regulatory body for nurses, midwives and health visitors, strongly advises all nurses in practice to have indemnity insurance through one of the professional organisations or trade unions. Of course, where new prescribers are employed by an NHS trust or primary care trust, NHS employers' liability will apply.
 As Committee members will know, the Health Act 1999 gave us the ability to require indemnity insurance for general medical and dental practitioners and the facility to extend that requirement to optometrists or pharmacists, the need for which we are keeping under review. For other professions, it is currently a matter for guidance and strong recommendation by the existing regulatory bodies. 
 I have thought carefully, and I think the issue is whether clause 60 is the right place for the provision and whether it should be specifically in relation to prescribing, or whether at some point it should be addressed more generally under the law relating to professions. My feeling is that this is not the appropriate place to take this measure although I recognise the arguments—and the reasons for them. The hon. Gentleman expressed some awareness of the dilemmas that are involved. If we were to be persuaded, however, that there was a need to enforce professions to have liability insurance, we should apply such a measure to the professions and not necessarily just in relation to clause 60 of this Bill.

Desmond Swayne: I thank the Minister for his comments and I concur largely with the analysis he has give, although I think that this is an that is worth considering further and we may do so. Meanwhile, I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn. 
 Clause 60, as amended, ordered to stand part of the Bill.

Clause 42 - Dispensing of NHS prescriptions and provision of pharmaceutical services

Amendment made: No. 213, in page 35, line 29, at end insert `; 
(i) any other description of persons which appears to the Secretary of State to be a description of persons whose profession is regulated by or under a provision of, or made under, an Act of the Scottish Parliament or Northern Ireland legislation and which the Secretary of State considers it appropriate to specify.'.—[Mr. Denham.]

Clause 43 - Remote provision of pharmaceutical, etc. services

Amendment proposed: No. 214, in page 37, line 6, at end insert 
`(whether by the Secretary of State or by another person so specified)'.—[Mr. Denham.]

Desmond Swayne: I do not wish to be a Luddite, but I do have reservations about remote prescribing. I would like the Minister to say a few words about what safeguards there will be because it strikes me that the advantage of the local pharmaceutical services is that they provide a higher-quality service. Many people may have become accustomed to that level of service and have enjoyed it, and the LPS scheme allows greater scope to develop that high quality of service to provide the added value that those pharmacy services can make available to the public.
 I wonder whether that added value is available by electronic mail. It is only by consulting the pharmacist that the medicine management that we have discussed today would allow the exploration of the interaction between a medicine that has been prescribed against medicines that were bought over the counter for other conditions. If pharmacy services are provided via electronic mail, is that added value to be had? The danger is that the provisions for remote prescribing have every possibility of denying patients the advantages of local pharmaceutical services. I am looking for reassurance from the Minister on that score—that the problems have been thought about and that safeguards will be in place.

John Denham: We are discussing an appropriate and sensible development. Clauses 42 and 43 remove legal obstacles to patients having their NHS prescriptions dispensed by mail order or by internet-based e-pharmacies. A small number of pharmacies in the United Kingdom sell medicines and, to a limited extent, dispense prescriptions. I said earlier that we do not intent to tell patients how they should have their prescriptions dispensed. Freedom of choice has always been at the heart of NHS dispensing. I do not see why NHS patients should be denied choices that are open to people with private prescriptions.
 The key factor is that mail order and on-line pharmacies must meet the same legal and professional standards as any other pharmacy. That means that all pharmacy and prescription-only medicines must be supplied only from registered pharmacy premises, and such premises are regularly inspected by the Royal Pharmaceutical Society of Great Britain. In addition, pharmacy and prescription-only medicines may be supplied only by, or under the supervision of, a registered pharmacist. For prescription-only medicines there must also be a prescription. Breach of any of those rules is a criminal offence. 
 As well as legal controls, there are professional controls. Pharmacists and e-pharmacists must have the same professionalism and ethical conduct as other pharmacists. They must also acknowledge the special issues that may arise when dealing with patients at a distance. 
 The Royal Pharmaceutical Society of Great Britain's code of ethics includes a standard for the provision of on-line pharmacy services. That standard requires on-line pharmacies to observe British Standards Institution standard BS7799 to ensure the confidentiality and integrity of patient information. It requires on-line pharmacies to ensure that people requesting a pharmacy-only medicine complete a questionnaire appropriate to the product concerned before a decision is made to supply it. If the request or the patient's answer suggests that he would better served by a face-to-face consultation, the pharmacist is required to refer the patient to a convenient pharmacy. 
 The standard also requires on-line pharmacies to keep records that identify the pharmacist who authorises every supply of a pharmacy or prescription-only medicine. For sales of pharmacy medicines, the records, which must be kept for two years, must give details of the transaction and the information upon which the decision to supply was based. Failure to comply would form the basis of a complaint of misconduct the statutory committee of the Royal Pharmaceutical Society of Great Britain, which has the power ultimately to strike off pharmacists found guilty of misconduct. In the case of a pharmacy company, the company's pharmaceutical superintendent be liable, as he would have personal responsibility for the management of the whole company's pharmacy business as well as for the pharmacy in question. Our view is that if those legal and ethical safeguards are met there is no reason why e-pharmacy should not safely provide patients with new choices in obtaining their medicines. 
 Clause 43 makes further amendments in consequence of the provisions in clause 41 that allow for the provision of pharmaceutical services by remote means. For consistency, it makes explicit that additional pharmaceutical services may include activities carried out away from the contractor's premises and across health authority boundaries. Additional pharmaceutical services are certain extra services that help authorities arrange with pharmacies under directions given by the Secretary of State rather than regulations. The clause makes a number of other essentially technical changes. 
 Amendment agreed to. 
 Clause 43, as amended, ordered to stand part of the Bill.

Clause 44 - Dispensing of NHS prescriptions

John Denham: I beg to move amendment No. 215, in page 37, line 23, leave out first `and'
 The amendment removes an extraneous ``and''. I assure the Committee that it is a purely technical amendment. 
 Amendment agreed to. 
 Amendment made: No. 216, in page 37, line 47, at end insert 
`(i) any other description of persons which appears to the Scottish Ministers to be a description ofpersons whose profession is regulated by or under a provision of, or made under, NorthernIreland legislation and which the Scottish Ministers consider it appropriate to specify.'.—[Mr. Denham.]
 Question proposed, That the clause, as amended, stand part of the Bill.

George Young: I have a short question: what on earth is the clause doing in the Bill? The clause amends the National Health Service (Scotland) Act 1978. Health matters have been devolved to the Scottish Parliament. As we shall discover when we reach clause 45, Scotland has enormous powers to do what it wants with health and social care without any reference to the United Kingdom Parliament. Despite that wide power to do what it wants, apparently it cannot vary the community of pharmaceutical services in Scotland without primary legislation in Westminster.
 I have looked at the back of the Bill to see who is supporting the legislation. The Minister and the Secretary of State for Health are, as is the Secretary of State for Wales, but the name of the Secretary of State for Scotland does not appear. There are no Scottish Labour Members on the Committee to help us with this difficult clause and—goodness me—there are not many Committees considering Bills on which Scottish Members can now serve, as they do not apply to Scotland. The Bill applies to Scotland, but there are no Scottish Members serving on the Committee considering it. 
 The explanatory notes state that they 
``have been prepared by the Department of Health, with assistance from the Wales Office''. 
There is no mention of the Scotland Office. Has some terrible mistake been made?

Lorna Fitzsimons: Is it not true that the right hon. Gentleman is among those who have sometimes been caught saying that there are too many Scots in Parliament?

George Young: The hon. Lady makes my point. There are a large number of Scottish Members of Parliament, whose presence is greatly appreciated. We would have welcomed one of them in the Committee today to help us through the clause.
 How much power rests with Westminster on Scottish health? Will we find that primary legislation in Westminster is required when other relatively minor changes need to be made to the health service? Did the draftsman made the mistake of not devolving the powers to Scotland in the Scotland Act 1998, and does the clause put that right? Will we come across a host of other anomalies in the months ahead?

John Denham: I can reassure the Committee that the parliamentary procedure surrounding devolution is so superbly designed that it allows the convenience of the measure being adopted in this way. The Scottish Parliament could adopt the measure but, under the Sewell convention, parliamentary procedures now allow it to agree that the Westminster Parliament can amend legislation that will apply to Scotland in this way. The Scottish Parliament has been through the necessary procedures under Sewell to allow that, so we are effectively responding to a request from the Scottish Parliament to amend its legislation.

George Young: I do not understand why the Scottish Parliament has to consult Westminster and needs us to change primary legislation for such a relatively trivial matter when it has enormous discretion, as we shall discover when we reach the next part of the Bill.

John Denham: As I understand it, it is simply more convenient for the Scottish Parliament to make use of Westminster's legislative powers in this way, as agreed under Sewell. It has happened in various pieces of legislation.
 We were worried this morning that we would not have time to complete the scheduled business today, but we seem to have nearly an hour left. We can therefore expect a lengthy discussion on devolution matters to take us up to 5 o'clock. 
 Clause 44, as amended, ordered to stand part of the Bill.

Desmond Swayne: On a point of order, Sir David. I wonder whether you could throw any light on the extraordinary exchange that took place in this Committee at 5.39 pm on 30 January 2001, when someone called Golf Whisky 1 said
 ``I think all this procedure is right—log's a bit confused and so am I'', 
to which Tango Mike Bravo 2 replied, 
 ``Unable to find a note on this''.—[Official Report, Standing Committee E, 30 January 2001; c. 265.]

David Madel: I need notice of points of order, and that is a matter for Hansard.
 Further consideration adjourned.—[Mr. Jamieson.] 
Adjourned accordingly at one minute past Four o'clock till Tuesday 6 February at half-past Ten o'clock.